Preconception health and care policies, strategies and guidelines in the UK and Ireland: a scoping review

Background Preconception health has the potential to improve parental, pregnancy and infant outcomes. This scoping review aims to (1) provide an overview of the strategies, policies, guidelines, frameworks, and recommendations available in the UK and Ireland that address preconception health and care, identifying common approaches and health-influencing factors that are targeted; and (2) conduct an audit to explore the awareness and use of resources found in the scoping review amongst healthcare professionals, to validate and contextualise findings relevant to Northern Ireland. Methods Grey literature resources were identified through Google Advanced Search, NICE, OpenAire, ProQuest and relevant public health and government websites. Resources were included if published, reviewed, or updated between January 2011 and May 2022. Data were extracted into Excel and coded using NVivo. The review design included the involvement of the “Healthy Reproductive Years” Patient and Public Involvement and Engagement advisory panel. Results The searches identified 273 resources, and a subsequent audit with healthcare professionals in Northern Ireland revealed five additional preconception health-related resources. A wide range of resource types were identified, and preconception health was often not the only focus of the resources reviewed. Resources proposed approaches to improve preconception health and care, such as the need for improved awareness and access to care, preconceptual counselling, multidisciplinary collaborations, and the adoption of a life-course approach. Many behavioural (e.g., folic acid intake, smoking), biomedical (e.g., mental and physical health conditions), and environmental and social (e.g., deprivation) factors were identified and addressed in the resources reviewed. In particular, pre-existing physical health conditions were frequently mentioned, with fewer resources addressing psychological factors and mental health. Overall, there was a greater focus on women’s, rather than men’s, behaviours. Conclusions This scoping review synthesised existing resources available in the UK and Ireland to identify a wide range of common approaches and factors that influence preconception health and care. Efforts are needed to implement the identified resources (e.g., strategies, guidelines) to support people of childbearing age to access preconception care and optimise their preconception health. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-024-19188-0.


Background
Preconception health describes the overall health of non-pregnant individuals of childbearing age (15-49 years) [1], and preconception care is defined as "the provision of biomedical, behavioural and social health interventions to women and couples before conception occurs" [2].Preconception care represents an excellent opportunity for the identification, screening, management and prevention of preconception health risk factors including, for example, parental obesity, longterm physical and mental health conditions, alcohol consumption, smoking, physical inactivity, inadequate dietary habits, poor social support and low immunisation levels [3][4][5][6].These preconception risk factors are widespread across the population [7], and individuals often live with more than one risk factor concurrently [8].The optimisation of preconception health provides an opportunity to improve individuals' wellbeing and promote positive intergenerational health, given the well-recognised association between parental and child health [9,10].
There has been an increased global recognition of the importance of preconception health and care in recent years [6], and reviews of preconception-focused guidelines and policies have been previously published.For example, an investigation of preconception policies, guidelines, recommendations and services was conducted across six countries, including the UK, and found heterogeneity in the advice provided [3].Given that these findings are related to searches conducted in 2013, a renewed investigation spanning the past decade was warranted and justified.Since then, a further review on preconception guidelines, recommendations and policy reports has been carried out [6].This review aimed to inform the reporting of populationlevel preconception health in England and led to the development of a comprehensive list of preconception indicators [6].A recent systematic review explored international clinical guidelines on preconception care, however it did not include guidelines specific to the UK or Ireland [11].
These previous reviews have played a critical role in advancing our understanding of preconception health and care.However, as the field of preconception care continues to grow and progress, it is important to collect, summarise and evaluate available contemporary resources.To the best of our knowledge, no previous scoping review has identified and comprehensively described the content of preconception strategies, policies, guidelines, frameworks and recommendations in the UK and Ireland.There is also limited knowledge on healthcare professionals' (HCPs) awareness and use of preconception health and care resources.

Research aims and objectives
This scoping review aims to provide insights for HCPs and policymakers, with the aim of improving preconception care delivery.Two primary objectives were established: (1) to conduct a scoping review to offer an overview of preconception health and care strategies, policies, guidelines, frameworks and recommendations from the UK and Ireland, and identify the common approaches and health-influencing factors addressed; and (2) to conduct an audit to validate available resources in Northern Ireland.The specific research questions this piece of work aims to answer can be found in Table 1.

Methods
A detailed research protocol has been previously published [12], with the main methodology summarised below.
This scoping review was conducted in accordance with the Joanna Briggs Institute's updated methodological guidance for scoping reviews [13] and Arksey and O'Malley's framework for conducting scoping studies [14].Reporting was informed by the Preferred Reporting Table 1 Research questions 1.What strategies, policies, guidelines, frameworks and recommendations have been developed that address preconception health and care for adults in the UK and Ireland between January 2011 and May 2022? 2. How does the evidence from strategies, policies, guidelines, frameworks and recommendations that address preconception care for adults differ across the UK and Ireland? 3. What are the main concepts and themes underpinning strategies, policies, guidelines, frameworks and recommendations that address preconception health and care for adults in the UK and Ireland? 4. What are, if any, the gaps in the knowledge provided in strategies, policies, services, guidelines, frameworks and recommendations that address preconception health and care for adults in the UK and Ireland, and what areas require further coverage and inquiry? 5. What are, if any, the services and interventions provided in Northern Ireland focused on improving preconception health and care in adults?
Items for Systematic Reviews and Meta-analyses extension for scoping reviews (PRISMA-ScR; see Additional file 1) [15].
Ethical approval was not required as the review analysed content from publicly accessible resources and the case study in Northern Ireland was conducted for audit purposes.

Search strategy
Searches were carried out on Google Advanced Search, National Institute for Health & Clinical Excellence (NICE), OpenAire, ProQuest and relevant public health and government websites using words and phrases such as "preconception health", "preconception care", "prepregnancy" and "preparation for pregnancy" (see Additional files 2 and 3 for full details).

Inclusion and exclusion criteria
The inclusion and exclusion criteria adopted are shown in Tables 2 and 3.

Data extraction and analysis
Identified resources were collated and uploaded into Microsoft Excel, duplicates were removed, and titles and summaries were screened.Following the methodology used by Godin and colleagues [16], the first 100 results on Google Advanced Search were screened for potentially relevant titles.The full texts of potentially relevant citations were assessed in detail, with ≥ 10% of resources being double-coded for inclusion in the review based on inclusion and exclusion criteria (EHC, LM).Any disagreements between the reviewers during the selection or coding process were resolved through discussion with the wider research team until consensus was reached, achieving multidisciplinary triangulation (disciplines included public health, psychology, and nutrition).NVivo 20 was used to manage the coded data and perform the content analysis (e.g., the identification of themes).
The term "resource" will be used throughout to indicate any retrieved record, including policies, strategies, guidelines, frameworks and recommendations.

Audit -Northern Ireland
An audit was undertaken in Northern Ireland to validate and contextualise findings from the scoping review, confirm the breadth of coverage and identify other potentially eligible resources.The audit was carried out through the dissemination of a brief checklist, exploring stakeholders' awareness and use of identified resources (see Additional file 4).It aimed to involve stakeholders working in the healthcare system in Northern Ireland, relevant services and organisations (e.g., maternity service providers, midwives, gynaecologists, obstetricians, general practitioners, nurses, pharmacists).Contacts of the research team, word of mouth and findings from Google Advanced Search were used to identify and invite stakeholders to participate.Stakeholders received the checklist via email, together with background information on the review.A smaller subset of stakeholders was asked to pilot the checklist and provide feedback before it was refined and distributed more widely.

Table 2 Inclusion criteria for resource selection
• Grey literature resources including strategies, policies, guidelines, frameworks and recommendations such as leaflets, booklets, webpages, and e-learning courses, discussing or addressing preconception health and care for individuals of childbearing age • Resources from the UK and Ireland • Resources written in the English language • Resources published, reviewed or updated between January 2011 and May 2022, thereby building upon the timeframe of a previous review [3] and allowing for more than a decade of content to be assessed • Resources providing specific advice, offering recommendations, or outlining policy actions or strategic plans to improve preconception health and care for individuals of childbearing age

Patient and Public Involvement and Engagement
Active involvement of the Patient and Public Involvement and Engagement (PPIE) panel "Healthy Reproductive Years" was achieved throughout the study.This advisory panel includes n = 23 adults aged 18-45 years old and living in Northern Ireland at the time of recruitment.Most of the panel members are female (n = 21) and did not have children at the time of recruitment (n = 11).Other demographic factors, such as ethnicity, were not collected.The panel members were recruited via numerous avenues including social media (e.g., Facebook) and relevant organisations (e.g., Sure Start).The PPIE strategies aimed to engage the public as partners [17], stimulate general discussions on preconception health and care to support priority setting, and advise on the research design and scoping review protocol [12], interpretation of results (including the terminology used and summary infographic), and dissemination plans.Engagement was carried out online (i.e., three workshops, exchange of emails), and representatives were financially remunerated in line with guidance from the National Institute for Health and Care Research [18].They were sent information about relevant PPIE training to further develop their skills and understanding of involvement in research, and a regular newsletter shared updates about the study's progression.
To report PPIE strategies, the Guidance for Reporting Involvement of Patients and the Public (GRIPP) 2 short form checklist was used [19] (see Additional file 5).

Terminology
The present review used the term "woman" throughout.This should be taken to include people who do not identify as women [20] but may become pregnant.The term was chosen to mirror the language used in a previous review, on which the present work builds on [3], and in the majority of the reviewed content, including resources from NICE (e.g., [20,21]).We acknowledge that others may prefer to use different terminology and that the preferred words may undergo further modifications in the coming years in this evolving field of study.

Results
This scoping review aimed to provide an overview of strategies, policies, guidelines, frameworks and recommendations addressing preconception health and care in the UK and Ireland.The searches were carried out in May 2022.After screening titles and summaries, 435 unique and potentially relevant resources were identified.Through audits with HCPs in Northern Ireland, five additional resources were identified, resulting in a total of 440 full-text resources for screening.Guided by the inclusion criteria (Table 2), 278 resources were included (Fig. 1; Additional file 6).

Overview of resources identified (Research question 1, Research question 2)
A wide range of resources addressing preconception health and care were identified and included.Specifically, the review included n = 25 policies, strategies, action plans, manifestos, interventions and frameworks, n = 6 e-learning resources, and n = 118 reports, guidelines, statements and toolkits, mainly targeting a professional audience.Additionally, there were n = 84 websites and n = 45 recommendations, which comprised leaflets and booklets designed for public use.There was overlap between the categories, meaning that, for example, a single resource could have been categorised as both a report and a strategy.Approximately half of the resources reviewed (n = 128, 46%) were designed for public usage (e.g., leaflets, websites), primarily targeting women.The remaining resources (n = 150, 54%) were directed at specific professional audiences (e.g., HCPs, service commissioners, policymakers, governmental departments), occasionally also targeting the public.When stakeholder engagement was mentioned in resources, this included audiences such as service users and the public.Men and partners were directly mentioned in 37.1% (n = 103) of resources.
Results showed that prior to 2015 only a limited number of resources addressing preconception health or care were published (< 10 per year).Since then, the availability of resources has increased.In 2021, the highest number of resources was made available (n = 52).
When assessing the input from each individual country, Wales was the country with the lowest number of included resources specific to the country (n = 11), while Ireland had the highest (n = 50).Most resources (n = 119) were relevant to all countries in the UK (i.e., England, Scotland, Wales and Northern Ireland).
In terms of the evidence sources referenced in the resources, frequent citations included NICE, Royal colleges such as the Royal College of Obstetricians and Gynaecologists and the Royal College of Psychiatrists, peer-reviewed journal articles and the National Health Service (NHS).Other references included Public Health England (now replaced by the UK Health Security Agency and Office for Health Improvement and Disparities) and charities such as Tommy's.There was cross-referencing between countries in the UK and Ireland, and certain resources also referenced international resources (e.g., from the United States).Many of the resources directed at the public, such as leaflets and websites, did not include reference lists or clear information on the sources of the evidence presented in the sections focusing on preconception health and care (n = 111, 39.2%).

What were the main themes identified? (Research question 3)
The content analysis of the included resources led to the identification of n = 36 themes, covering both commonly-proposed approaches to improve preconception health and care delivery (n = 9), and protective and risk factors that can influence preconception health (n = 27) (Fig. 2, where the size of nodes reflects the frequency of mentions).The results pertaining to the proposed approaches, which ultimately refer to actions that can help shape relevant services in the future, were presented mostly in resources for a professional audience, whereas health influencing factors were discussed in resources for both professionals and the public.

Approaches to improve preconception health and care
The importance of providing preconception advice and counselling was emphasised in 45% of the available resources (n = 125).Recommendations to improve the delivery of advice included a) avoiding overwhelming people by providing excessive information in a single instance; b) avoiding apportioning blame or guilt; c) including men, partners, family members or peers when accepted and appropriate; d) acknowledging societal and cultural factors, unconscious bias, and any barrier that may prevent the adoption of preconception health-promoting behaviours (e.g., financial circumstances, personal experiences, lack of support, and physical, sensory, cognitive or learning disabilities); and e) adopting a blended format (e.g., a single leaflet could combine messages on both folic acid supplementation and pre-pregnancy weight) [22][23][24][25][26][27][28].Appropriate settings for the delivery of preconception care mentioned included both medical (e.g., pharmacies, doctor surgeries, family planning clinics, abortion and fertility clinics) and non-medical settings (e.g., community and youth centres, faith groups, hostels) [4,25].
Resources advocated for interdisciplinary collaborations among professionals (n = 75, 27%) (see Additional file 7), alongside efforts to upskill HCPs (n = 34, 12.2%) on topics such as mental health, bodyweight-related issues, suitable folic acid supplementation messaging, and identification of domestic abuse [29][30][31][32][33][34][35].Resources also supported the adoption of a life-course approach (n = 31, 11.1%) and highlighted the importance of improving access to preconception care (n = 31, 11.1%), increasing awareness of preconception health and care (n = 30, 10.8%), and maintaining continuity of care where applicable, by involving HCPs such as GPs and specialists to create coordinated healthcare provision across different life stages and settings (n = 14, 5%).To increase awareness and understanding of preconception health and care from an early age, schools were particularly highlighted (n = 14, 5%).Finally, nine (3.2%) resources recognised the need for improved health surveillance and suggested enhancing data collection processes, including improving the quality and completeness of maternity data recorded at booking appointments.The frequency of each of these approaches is shown in Fig. 3.

Preconception health-influencing factors
A wide range of preconception health-influencing factors was addressed in the reviewed resources, including biomedical (e.g., physical health conditions), behavioural (e.g., smoking), and social and environmental factors (e.g., wider determinants of health).The presence of pre-existing physical health conditions was the most highly cited health-related factor (n = 155, 55.8%), and it was often linked to medication use (n = 149, 53.6%).Diabetes (n = 93) and epilepsy (n = 39) were the most frequently mentioned conditions, and sodium valproate (n = 23) was the most frequently mentioned medication.Mental health conditions were mentioned less frequently (n = 81, 29.1%), although there was a recognition that mental health services require improvement.Folic acid supplementation was detailed in 50% of the included resources (n = 139).In particular, the supplementation of 400μg/day was recommended in n = 50 resources, and the higher dose of 5mg/day in n = 56 resources, including resources that did not solely aim to provide advice for people with increased medical risks.Among the observed behaviours, sleep was mentioned the least frequently (n = 3, 1.1%).
Forty-eight (17.3%) resources emphasised the influence of wider determinants on preconception health, including socioeconomic status and ethnicity.Resources proposed that multi-faceted preconception interventions should be designed to prevent and reduce health inequalities, and supported individualised approaches tailored to those experiencing different needs (e.g., based on ethnicity, culture, financial limitations, life circumstances) (e.g., [4,34,36,37]).
All identified preconception health-influencing factors, and the frequency of mentions, are presented in Fig. 4. Excerpts from the three most commonly observed factors can be found in Table 4.
Advice provided regarding preconception health-influencing factors was often accompanied by information concerning associated adverse maternal and infant outcomes.For example, when discussing pregnancies among young individuals (e.g., under 20 years of age), resources often covered the description of potential risks, including stillbirth, infant mortality and poor maternal mental health, as well as associated risk factors such as smoking and unplanned pregnancies (e.g., [4,38,39]).For most of the behaviours, advice included having conversations with HCPs, who were encouraged to avail of referral pathways to ensure adequate support.The included resources recommended that healthcare services should incorporate discussions on preconception health behaviours as part of routine practice [40,41].However, resources addressing preconception health-influencing factors also highlighted that available support is currently unsatisfactory and access to care is inconsistent in many Fig. 3 Frequency of reporting of proposed approaches to improve preconception health and care areas (e.g., smoking cessation, fertility services) [40,42].This may be attributed to the fragmented design and delivery of services [40].In this review, inconsistencies were found in relation to some of the advice provided, for example regarding safe preconception alcohol intakes, recommended physical activity levels, and dietary habits including caffeine consumption.For instance, while certain resources suggested that caffeine should be limited to 200mg/day, others proposed there is no robust evidence to support such recommendations [43][44][45][46][47][48].

Gaps in knowledge (Research question 4)
Certain knowledge gaps were emphasised in the resources reviewed.For example, resources highlighted the need to further investigate the most suitable preconception care delivery methods and interventions, and particularly mentioned interventions aiming to promote physical and mental health, lower levels of alcohol consumption before pregnancy for both men and women, and improve the uptake of folic acid supplementation [49,50].The resources also recognised the need to further investigate topics such as the predictors of preconception care engagement and to advance the current understanding of preconception health-influencing factors and related health conditions (e.g., [22,46,51]).Although many resources acknowledged the influence that wider determinants can have on preconception health, resources also highlighted that further efforts are required to adequately address the major disparities that persist (e.g., in relation to ethnicity and socioeconomic status) [26,27].Suggestions included the development of suitable preconception weight measurement methods for minority ethnic groups, and tailored ways to promote the uptake of folic acid and other supplements among disadvantaged groups [34,50].

Audit -Northern Ireland (Research question 5)
Seventeen HCPs in Northern Ireland completed the audit checklist, including five (diabetes) specialists, five general practitioners (GPs) and a GP trainee, three midwives, two pharmacists, and an endocrinologist.Fifteen participants were aware of the NICE Clinical Knowledge Summary on preconception advice and management [21], with the majority (n = 11) reporting its routine use in preconception care.Of the specialist NICE resources, the one focusing on the management of diabetes from  the preconception to the postpartum period [52] was most often recognised.Most participants were aware of guidelines from the Royal College of Obstetricians and Gynaecologists, and specifically mentioned guidelines focusing on obesity, epilepsy, diabetes and mental health issues (e.g., [53,54]).Another resource most participants (n = 15) were aware of and routinely used in preconception care was a brief guideline by the Northern Ireland Public Health Agency, a body responsible for providing health protection and improvement in Northern Ireland, on the topic of folic acid and vitamin D [55].Awareness of relevant preconception health and care policies, strategies, reports and e-learning resources was not notably prevalent.Similarly, the use and awareness of leaflets and web pages directed at the public was generally poor, except for the NHS web page titled 'Trying to get pregnant' [56] (n = 13), and those addressing the management of diabetes when planning pregnancies (e.g., [57,58]).
The frequency of participants' self-reported awareness and use of selected reviewed resources is presented in Fig. 5.
The audit identified two additional resources that were not identified in the searches [59,60].One participant also mentioned using the Mum and Baby Academy website, a UK-based online provider of academicallyapproved free courses for professionals, for continual professional development [61].This website was searched, and three additional e-learning courses were included in the review [62][63][64].

Patient and public involvement and engagement
Early engagement with eight PPIE representatives during two workshops indicated their belief that preconception health is an important aspect of health, thereby helping with the conceptualisation of the review and priority setting.Subsequently, two PPIE representatives (DT, TS) directly collaborated on the review protocol [12], and provided feedback on the interpretation of the results.Overall, they expressed an interest in the topics under review asking about health-influencing factors the public may not be familiar with (e.g., pelvic floor health, artificial reproductive technologies), suggesting clarifications on certain concepts and mechanisms (e.g., the practical implementation of a life-course approach, the specific strategies that can raise the public's awareness of preconception health and care), and inquiring about knowledge gaps (e.g., the reasons why access to care is lacking).A further workshop was held with three other PPIE representatives to design a summary infographic (Fig. 2).In the discussions that unfolded during this workshop, representatives suggested that many individuals seek preconception health-related advice only if experiencing difficulties conceiving, and highlighted the importance of increasing preconception health and care awareness from an early age.

Overview of resources identified
This scoping review identified a large number of policies, strategies, guidelines, frameworks and recommendations in the UK and Ireland addressing topics related to preconception health and care (n = 278).These resources recognised the period preceding conception as an opportunity to optimise preconception health, by identifying common approaches for preconception health and care optimisation and a wide range of preconception healthinfluencing factors.Preparation for pregnancy was emphasised for women more than for men or same sex partners, and especially those with pre-existing physical and mental health conditions.Accessing women's health services was recognised as challenging and fear-inducing for people with pre-existing conditions planning a pregnancy [65], which can result in poorer access to care, unplanned pregnancies or avoidance of pregnancy altogether [40].
In this review, a wide variety of resource types were identified for healthcare professionals and the public, including, for example, policies, strategies, action plans, e-learning resources, reports, guidelines, leaflets, and booklets.However, the preconception period was often not their primary or sole topic.This finding is supported by a previous review on the availability and quality of guidelines for preconception care, which identified numerous guidelines referring to preconception but only 11 guidelines primarily focusing on preconception care [11].Many websites with recommendations and guidance were found, which may be considered promising as digital platforms can have a wider reach, promote behaviour change, and be suitable for educational purposes at scale [66,67].Online engagement is especially opportune when resources are easy to access, reputable, evidencebased and, where applicable, include advice from peers with similar experiences [66] or interactive elements.Mobile phone apps may also support the optimisation of preconception health, although the evidence is limited [68].Other public-facing resources identified were booklets and leaflets which provided useful information, but seeking relevant professional advice before taking or avoiding actions based on the information relayed in these materials was often encouraged.
The findings of the review showed that, since 2015, the availability of resources has increased, perhaps suggesting increased awareness of the benefits of preconception health and care.However, the establishment of a strong culture of preconception care in the UK and Ireland still necessitates dedicated efforts and co-produced interventions.

Main themes identified
Nine different approaches were identified for improving preconception health and care.However, many of these rely on the role of HCPs and health services, thus reflecting the scope of many resources that was mainly confined to clinical rather than public health settings.Similar to other pressing healthcare priorities, the progression towards the establishment of a culture of preconception care necessitates a significant allocation of resources.One of the barriers to provision of preconception care is the limited capacity of healthcare systems and other networks to provide timely and accessible preconception care.Unrealistic expectations placed solely upon HCPs who are working within an already pressurised healthcare system should be avoided.Other awarenessraising opportunities outside the healthcare system were mentioned, including schools and (digital) media campaigns.Overall, a multi-level approach to preconception care combining bottom-up mobilisation of individuals and communities with public health top-down initiatives from governmental bodies was encouraged [34,36], with particular support for initiatives designed with stakeholders (including the public).
This review also identified many modifiable and nonmodifiable preconception health-influencing factors, placing stronger emphasis on clinical characteristics such as pre-existing physical health conditions, and to a lesser extent mental health conditions.However, there was a recognition that preconception health risk and protective factors do not occur in isolation but are interconnected and often clustered, with pregnancies not being conceived in isolation from "the ocean of socioeconomic, cultural, family, corporate, governmental/political forces surrounding it" [69].Certain inconsistencies were identified concerning physical activity, caffeine consumption and alcohol intake in both men and women, indicating a need for clearer and more consistent advice (although variations may also be influenced by changes in recommendations over time).Efforts should be made to remove contrasting and potentially outdated advice, especially in online resources.

Building on previous research
The present review aimed to build upon a previous review of preconception care policy, guidelines, recommendations and services [3].The previous review identified a focus on recommendations for women with chronic diseases and, while the current review found a substantial number of resources available for all women, pre-existing physical health conditions were frequently mentioned.Both reviews found a limited focus on men, identified heterogeneous advice, and overall highlighted a need for the development of evidence-based resources for preconception health and care, to accompany a clear strategy for health promotion across the childbearing population [3].However, there are also differences between the two reviews.One way to illustrate these differences is through the varied guidance provided regarding alcohol consumption.The advice presented pertaining to the UK from the earlier review indicated that women should limit their alcohol intake to 1-2 units once or twice a week, while the advice from the current review exhibited great variability, with abstinence also being suggested.Additionally, the present review encompassed information regarding the fortification of flour with folic acid, a topic that was still under consideration in the UK during the publication of the prior review [3].

Further research
This review identified gaps in knowledge, offering recommendations for potential future research.For example, further efforts should aim to investigate preconception care engagement, preconception health-related factors and conditions, delivery of non-conflicting advice, and suitable interventions (e.g., to promote physical and mental health) [22,49,70].This may help clarify the inconsistencies found in the advice provided.While many approaches that can be used to improve preconception health and care were identified in this review, further research needs to be undertaken to explore clear and innovative preconception health-promotion means, and address the needs of diverse populations at different life stages across the reproductive life span [70].Although many resources acknowledged the influence wider determinants can have on preconception health, research is still needed to further investigate how to suitably address the ongoing disparities in relation to ethnicity, socioeconomic status and further inequalities (e.g., educational attainment) [26,27].Overall, findings from this review indicate that further efforts are required to foster and support the development of a culture of preconception care, also including men and partners when applicable.

Audit -Northern Ireland
Auditing HCPs' use and awareness of preconception care resources in Northern Ireland contextualised the review findings, offering insights on the reach of identified resources.The audit led to the identification of five additional resources, reinforcing the comprehensiveness of the review.Most participants were aware of the NICE Clinical Knowledge Summary resource on preconception advice and management [21], and there was repeated recognition and use of resources on diabetes management, although this finding may be influenced by the inclusion of specialist diabetes nurses.Overall, the audit supported the results of this review, reinforcing the need for further upskilling of HPCs on topics related to preconception health and care (e.g., mental health, paternal factors).Overwhelming HCPs with new resources or solely relying on them may, however, not be desirable.While referral pathways for specialist cases may be used, the results of the review suggested that there is still need for improvement in how these are implemented.However, this may be limited by resource allocation within the healthcare system.

Patient and public involvement and engagement
Representatives from the PPIE panel were invited to coproduce this scoping review.There was a level of interest shown towards preconception health and care, as representatives believed preconception health to be an important aspect of health and wanted to deepen their knowledge on the evidence available.They asked for further clarifications on certain aspects of preconception health and mentioned the importance to increase awareness from an early age.Overall, PPIE strategies suggested that the public may be receptive to preconception healthrelated messaging, if presented in a clear yet thorough way, and emphasised the importance of tailoring the delivery of advice to align with the interests and concerns of the public.

Strengths and limitations
This scoping review was conducted to explore the breadth of grey literature on preconception health and care populating the scene for over a decade in the UK and Ireland.A systematic approach was followed, thus locating, synthesising and presenting evidence from a broad and diverse topic in a clear manner, accessible to stakeholders [14].The addition of the audit undertaken to explore preconception care in Northern Ireland with 17 HCPs represents a further strength, as well as the contribution and input from PPIE representatives.The panel included between 18 and 45 years old, and engaging with younger and older people with reproductive potential may provide additional insights on their desires and interests.
Because the study was intended as a broad scoping review, it included a heterogenous group of resources.Resources explicitly addressing only the interconception period were excluded, although it is recognised as an important time during which individuals are likely to engage with health-promoting messages and be in frequent contact with HCPs [71].Regardless of the measures taken to limit missing relevant citations, potentially eligible resources may have been missed due to the limited number of databases searched, the language restriction applied to the searches, the narrowed timeline and the search terms used.Additionally, relevant resources may have been missed if not available online.However, this limitation was minimised by the inclusion of the audit in Northern Ireland, which allowed the identification of five additional resources.By including Google Advanced Search, the replicability of the searches is limited due to the algorithm governing these types of searches [72].Moreover, the quality of the advice provided in the public-facing resources included in this review was not assessed.Finally, because this review focused only on the evidence available in the UK and Ireland, findings may not be generalisable to other countries.

Conclusion
This scoping review identified and analysed preconception health-related policies, strategies, guidelines, frameworks, and recommendations in the UK and Ireland (n = 278).It identified several approaches to optimise preconception care delivery, mainly in resources directed at a professional audience, as well as preconception healthinfluencing factors, of which pre-existing health conditions were the most frequently mentioned.A specialised audit contextualised the findings relevant to Northern Ireland by highlighting the use and awareness of identified resources among HCPs.
The reviewed resources advocated for both better individual support and structural improvements to optimise health outcomes, and identified the need to further investigate preconception health-related factors.While more research is still needed (e.g., to address the inconsistencies in preconception health messages, tackle inequalities, support the widespread implementation of guidelines), this review provides an overview of resources available to HCPs and the public that can be used to optimise preconception health and care.

Fig. 1
Fig.1PRISMA flowchart.*Only the first 100 results for each Google Advanced Search searches were screened, following the methodology presented by Godin et al.[16]

Fig. 2
Fig. 2 Commonly-proposed approaches to improve preconception health and care and preconception health-influencing factors

Fig. 4
Fig. 4 Frequency of reporting of identified preconception health protective and risk factors

Fig. 5
Fig. 5 Self-reported awareness and use of selected reviewed resources among audited healthcare professionals (n = 17).Abbreviations: NICE: National Institute for Health & Clinical Excellence; RCOG: Royal College of Obstetricians & Gynaecologists; PHA: Public Health Agency; NIHR: National Institute for Health and Care Research; MBRRACE: Mothers and Babies -Reducing Risk through Audits and Confidential Enquiries across the UK; MHRA: Medicines and Healthcare products Regulatory Agency; RCPSYCH: Royal College of Psychiatrists; RQIA: Regulation and Quality Improvement Authority; E-LFH: E-Learning For Healthcare; NHS: Nation Health Service; NI: Northern Ireland; HSCT: Health and Social Care Trust

Table 3
Exclusion criteria for resource selection

Table 4
Excerpts extracted from reviewed resources, pertaining to the three most cited themes